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Search Terms: mental AND health AND parity, House or Senate or Joint

Document 15 of 103.

May 18, 2000, Thursday

SECTION: PREPARED TESTIMONY

LENGTH: 3029 words

HEADLINE: PREPARED STATEMENT OF STEVEN E. HYMAN, M.D. DIRECTOR NATIONAL INSTITUTE OF MENTAL HEALTH

BEFORE THE SENATE HEALTH, EDUCATION, LABOR, AND PENSIONS COMMITTEE

BODY:
Mr. Chairman and Members of the Committee:

I am Dr. Steven Hyman, director of the National Institute of Mental Health (NIMH). I am delighted to participate in this important and timely heating on mental health insurance parity, sharing this panel with my colleagues from the General Accounting Office. I am deeply appreciative of the sustained attention that Senator Domenici and Senator Wellstone have directed to the issue of mental disorders and I thank the Committee for its interest in the topic.

Over the past two decades, NIMH has assigned priority to research on the organization and financing of mental health services. Within the past 8 to 10 years, at the request of the Senate Appropriations Committee, the Institute and its National Advisory Council have developed a series of reports on parity of insurance coverage between mental disorders and general medical disorders. Three of the Reports, developed in 1992, 1997, and 1998, are compiled in a document that is currently available from NIMH, electronically on our home page (www.nimh.nih.gov) and as a monograph. A fourth report is undergoing final review as we speak. I will not address technicalities of the economics research relevant to consideration of parity. Rather, I would like to broaden the context of the Committee's consideration of parity by discussing some of the mental illness research findings that have brought us to a point where this heating is a next needed step in consideration of our Nation's mental health policies. Specifically, I will present research findings indicating that mental disorders are "real" and often tragically disabling illnesses that affect millions of Americans; that these are disorders of an organ, the brain, just as coronary arterydisease is a disorder of another organ, the heart; that these disorders can be diagnosed with a high degree of reliability; and that treatments of well-documented efficacy exist. Growing appreciation of these points accounts for and is reflected in significant changes in public attitudes about mental illness.

The release last December of the first-ever Surgeon General's Report on Mental Health was a landmark event in this ongoing sea change in public understanding and attitudes. Dr. Satcher brought front and center to the American public a scientific discussion of topics that desperately need open and continuing discussion. I might note that the NIMH web site that I mentioned earlier, that links to the Surgeon General's Report and also provides abundant information on specific mental disorders and on NIMH-funded research, has been visited by more than 6-and-a-half million people just within the past month. After a dismally long period marked by stigma and misunderstanding, Americans are hungry for information about mental disorders and mental health.

The Burden of Illness

What impact do mental disorders have on our society? A watershed in our understanding of the impact of mental disorders is the 1996 Global Burden of Disease (GBD) study, conducted for the World Bank and World Health Organization by Drs. Christopher Murray and Allen Lopez of Harvard University. This study examined 483 separate consequences of 107 diseases and injuries with the recognition that traditional measures of disease burden, such as prevalence or mortality, do not really lay bare the impact of disease on economies or on societies at large. For example, colds are highlyprevalent but cause no serious impairments and sudden death in old age has little economic impact. The GBD defined a concept called the Disability Adjusted Life Year (DALY), which refers to healthy years of life lost to either disability or premature mortality. Based on this measure of disease burden, mental disorders - which are prevalent, often begin early in life, and frequently are characterized by recurrent episodes (as in depression) or chronicity (as in schizophrenia) - produce a disproportionate share of DALYs, much of which is due to disability. Indeed, according to the GBD, in the U.S. - and throughout the developed world - depression is the leading cause of disability, and bipolar disorder, schizophrenia, and obsessive-compulsive disorder are found among the top ten causes (see Table 1).

The study's authors note: ".. The burdens of mental illnesses, such as depression, alcohol dependence, and schizophrenia, have been seriously underestimated by traditional approaches that take account only of deaths and not disability. While psychiatric conditions are responsible for little more than one percent of deaths, they account for almost 11 percent of disease burden worldwide."

There remain, of course, methodologic problems in quantifying disability, and these problems are even more pronounced in quantifying disability in children. Nonetheless, the Surgeon General's report estimates that approximately 20 percent of those under age 18 have mental disorders that result in mild functional impairment; a smaller subset of children - between 5 and 9 percent - experience severe functional impairments; by that, I mean they are severely limited, or handicapped, in their ability to interact happily and healthily with their families and friends, to engage fully in school activities and to acquire the skills and knowledge that set the developmental path for aproductive, satisfying adult life. For children, an untreated mental illness is doubly tragic because it may not be possible to recover the lost period of learning and social development needed to produce healthy, skilled, and productive individuals who can live up to their innate potential. Moreover, there is increasing evidence that, as in all chronic diseases, the earliest possible diagnosis and intervention may minimize severity and ultimate functional impairment. Recent tragic episodes of violence in our schools remind us that inadequately treated emotional and behavioral disorders among our children can literally have lethal consequences in terms of suicide and murder. Of course, untreated mental disorders in children also markedly impair the ability of parents to work productively. The need for appropriate treatment of childhood mental illness is vital, and the payoff is immense.

A steadily improving, research-based understanding of disability, or the functional impairments associated with illness, is critically important, for policy deliberations often come down to tough decisions about how best to use limited resources - public and private - to provide effective care for those problems that cause the greatest disability. This point is particularly germane to consideration of insurance parity. The Global Burden of Disease data make it strikingly clear that we cannot have a healthy work force in the United States, or for that matter a nation of children behaviorally and emotionally ready to learn in school, without broad access to high-quality treatment for mental illnesses. It is fortunate that at the same time research is documenting the perils of failing to treat mental and behavioral disorders, it also has shown that mental disorders can be diagnosed with an adequate degree of certainty.For the most common mental disorders, efficacious treatments exist that, for the most part, are as good or better than treatment for most of the chronic somatic illnesses of greatest concern in the United States. Dr. Ronald Kessler and colleagues recently analyzed data from two national surveys and found that the odds of having any short-time work disability are 37- to 48% higher among employees with major depression than among all other workers (17- to 21%). Untreated depression leads workers to miss between 1.5 and 3.2 more workdays in a month than all other employees, resulting in salary-equivalent disability costs averaging between $182 and $395 per depressed employee.

Data from a recent primary care depression treatment trial found the cost of effective pharmacotherapy for depression to be $402 per 30 depression-free days; thus, the investigators estimate that between 45% ($182/402) and 98% ($395/402) of the costs of treating the employees' depression would be offset by increased work productivity associated with symptom remission. The researchers noted, moreover, that the costeffectiveness margin for employers may be even greater, since untreated depression entails additional hidden costs and because employees, rather than employers, pay insurance costs over the long term in the form of wage adjustments (Kessler et al, Health Affairs, 18. (5):163-171, 1999)

Research on the Brain and Behavior in Mental Illness

A broad scope of research, including neuroscience, genetics, brain imaging, behavioral science, and clinical investigation has taken us far beyond the impoverished and stigmatizing conceptions of diseases such as schizophrenia, autism, or manicdepressive illness left us by history.Perhaps, the most important message I can leave with the Members of the Committee today as you deliberate how we treat mental disorders is that we have found no reason based on biomedical or behavioral science why mental disorders should be treated differently from any other medical disorder. Try to explain to the family member of a person with schizophrenia why Parkinson's disease - a chronic and not yet curable disease that affects dopamine systems in the brain - might be fully covered by insurance while schizophrenia - another chronic and not yet curable disease that affects dopamine systems in the brain - is not. Think of how you might explain to the parent of an autistic child why chronic genetic diseases that cause childhood seizures might be fully covered but why a highly genetic brain disease such as autism is not.

Studies of Genes and Mental Disorders

Based on family and twin studies, there is no doubt that the major mental disorders are genetic disorders. Indeed, the genetic risk associated with autism is greater than that observed for such general medical disorders at type II diabetes mellitus (See Table 2). While diseases like schizophrenia, autism, manic-depressive illness, major depression, attention-deficit/hyperactivity disorder, anorexia nervosa, and many others are genetically complex, meaning that risk is due to a combination of multiple genes and nongenetic, or environmental, factors, we are well on the way to discovering the relevant genes. This is the same state of genetics research in many other common illnesses with genetic components of risk such as the common forms of type II diabetes or coronary artery disease.

Studies of the Brain in Mental Disorders

The control of thinking, emotion, movement - indeed, all behaviors - depends on the function of many specific "circuits" in the brain. These circuits are composed of nerve cells that communicate with each other by means of chemicals called neurotransmitters. Disease can attack the brain in several ways that alter its function and, in turn, mental life and behavior. The simplest case is when brain cells die. This happens, for example, in a stroke, when a blood clot deprives cells of oxygen. The precise behavioral deficit created by a stroke depends on which cells die and, therefore, which circuits are disrupted. Alzheimer's disease, considered a mental illness until recently (indeed the distinction between mental disorders and many other brain diseases is quite arbitrary), is a disease in which abnormal substances, called plaques and tangles, accumulate in nerve cells, eventually resulting in their death.

ln strokes and Alzheimer's disease, we can look in a microscope and see dead or dying cells and other brain pathology. But the brain can malfunction substantially even without cells dying or displaying pathologic structures: If the brain is "wired up" incorrectly during brain development, as we believe to be the case in autism and schizophrenia, there are terrible behavioral consequences without dramatic gross or microscopic pathology. Specific neuropathology has been identified, however, in schizophrenia, in the form of changes in the ventricular system in the forebrain, and various other morphological changes have been reported as well. At the same time, it is important to separate research findings from clinically useful tests: Although today there is no single abnormality on a brain scan that would allow us to make a diagnosis of schizophrenia in an individual, from the point of view of research, brain abnormalitiesthat are characteristic of schizophrenia have been solidly established. Fortunately, for clinical purposes, the symptoms and behavior generally make the diagnosis clear.

One step farther from the example of a stroke is a severe mood disorder, such as major depression or manic-depressive illness. A person suffering one of these recurrent, episodic disorders may function entirely normally prior to the onset of illness, and may have periods of remission in which they function normally again. We do not believe that these individuals suffer gross nerve cell death or fundamental miswiring or else they could not improve with treatment to the point of normalcy. Diseases like manicdepressive illness represent serious, but reversible abnormalities in the function of specific brain circuits. This is not hocus-pocus; we are quite familiar with this kind of disease in medicine. Each year several thousand Americans die of an abnormal heart rhythm called ventricular fibrillation. Many of these people have never had a heart attack. On a postmortem examination, the pathologist does not see a malformed heart or even an abnormal pattern of wiring in the heart. What has killed these people is potentially reversible, but often lethally abnormal electrical activity in the anatomically normal circuits that control their heart rhythms. In the case of mania or depression, what disables - and all too often kills - is abnormal functioning of specific neural circuits as a result of genetic vulnerability acting together with triggers from a person's environment or experience.

Over the next decade, we almost certainly will discover the genes that create vulnerability to the miswiring of schizophrenia and of autism and to the abnormal circuit function of mood disorders.

Coverage of Mental Health Care

At the beginning of my statement, I noted that that NIMH, through its National Advisory Mental Health Council, has been directed to undertake several studies examining the question of parity in financing mental health services. In 1992, the Senate Appropriations Committee asked the Council to prepare a report "on the cost of covering medical treatment for severe mental illnesses commensurate with other illness and an assessment of the efficacy of treatment" for designated disorders. In its report accompanying the 1997 appropriations bill, the Committee requested that the Council report on then-available data about the costs of providing equitable coverage for people with "severe and clearly identifiable, diagnosable, and treatable" mental disorders. In the following year's report, the Committee requested additional reports as data became available, and inquired explicitly about the impact of managed care on access to mental health services, and on the quality of the care that is made available."

Most recently, the Committee requested health services research data that would, where possible "...address both employer direct costs, and the impact of indirect cost savings from successful treatment of employees." The Advisory Council was asked also to "consider the costs and quality of coverage for children, and the development of outcome measures of quality for all mental health coverage."

That inequities related to the status of mental disorders in health insurance exist is indisputable. While keeping overall health care costs within bounds is a matter of importance to all Americans, the research that I have described today shows no biomedical justification for differentiating serious mental illness from other serious and potentially chronic disorders of the nervous system such as stroke, brain tumor, orparalysis. That. is, there is absolutely no biomedical justification for policies that judge mental disorders as being in any way less real or less deserving of treatment, and an extensive body of rigorous research has demonstrated that treatment for mental disorders is both precise and cost-effective.

Given the onset of many mental disorders in childhood, adolescence, and early adulthood, and the serious repercussions for the long-term productivity of members of our society of leaving these disorders untreated, the need for access to treatment seems particularly acute.

NIMH takes seriously its responsibility for supporting the wide array of research needed to demonstrate that mental disorders are real, diagnosable, and treatable. It is on the foundation of this research that NIMH responds to requests, such as those from the Senate Appropriations Committee, to examine various issues related to insurance benefits for mental health treatment.

According to our most recent analysis, both new research and re- estimates of previous efforts to model the impact of parity initiatives, indicate that implementing parity benefits does not cause any substantial increases in health treatment costs. One recently updated simulation model estimates an increase of approximately 1.4 percent in premium costs when parity is implemented. Hard data from one large State show, moreover, that total health care costs decreased after implementation of parity.

NIMH will continue to study and monitor the impact of parity in the years ahead. At present, 30 States have passed some form of parity legislation. The models adopted by different States vary widely, with benefits that range from limited to comprehensive. These programs afford the Institute and the Nation a wealth of opportunities to assess theimpact of parity initiatives. A critical question that remains to be answered, of course, is what impact mental health insurance parity has on the quality of care and its implications for public health.

Thank you, Mr. Chairman. I will be pleased to answer questions.

END

LOAD-DATE: May 19, 2000

Document 15 of 103.


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